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Birth and death

MANILA, Philippines—Birthing has always been a women’s ritual. Before the natural birth movement brought fathers not just into the labor room but in birth classes too, men were largely absent from the entire process of pregnancy and birth—except, of course, for donating the sperm (knowingly or unknowingly) that sets the women down that road.From the moment a woman finds out she’s pregnant, she finds herself cocooned in a circle of advice and counseling, helpful or otherwise, from other women, even those who have yet to be with child. She is told what she should and should not eat, how to have a good-looking child (by clipping a picture of a cute baby and placing it beneath her pillow), how to avoid stretch marks and unwanted pigmentation (usually useless), even when and how to have sex despite the watermelon in her belly.The sisterhood makes itself felt particularly during delivery. In the days before the “medicalization” of birth, a woman delivered at home, cared for by a birth attendant, and surrounded by women boiling water, preparing concoctions, washing linen and praying novena after novena for her and the baby’s survival.The father and his men friends and relatives would be waiting outside the delivery chambers or in the backyard or even at a nearby sari-sari store or bar. When hospital deliveries became common, fathers would be consigned to a waiting area, playing out the cliché of the anxious parent pacing back and forth and, when it was still politically correct, smoking stick after stick and littering the hospital floor with cigarette butts.Being absent from the scene, fathers often took the process for granted, or else took inordinate credit for the outcome. An old professor of mine, a mother of 12, has a favorite story about her late husband. As she swam out of the anesthesia after the birth of their oldest child, a girl, her husband looked lovingly into her eyes and said gently “We have a girl, but don’t worry, the next one will be a boy.”

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DESPITE the romanticism of the sisterhood looking after their own at the time of a woman’s delivery, the truth is that the moment of birth and the period immediately after it is fraught with risk for both mother and child.In a policy paper on “Saving Newborn Lives” published by Save the Children and the Population Reference Bureau, the authors posit that “Newborn survival is inextricably linked to the health of the mother. Nowhere is this more evident than the high risk of death for newborns and infants whose mothers die in childbirth.”For both newborns and mothers, says the paper, “the highest risk of death occurs at delivery, followed by the first hours and days after childbirth. The postnatal period (the time just after delivery and through the first six weeks of life) is especially critical for newborns and mothers.”More than two-thirds of newborn deaths take place by the end of the first week after delivery, with up to one-half of all newborn deaths occurring in the first 24 hours. Each year, four million infants die within their first month of life, representing nearly 40 percent of all deaths of children under 5.Similarly, approximately two-thirds of all maternal deaths occur in the postnatal period. Says the paper: “The time of highest risk of death is the same for mothers and for newborns—on the day of delivery and over the next few days after delivery.”These data, the authors say, “offer compelling evidence that integrated maternal and newborn postnatal care (PNC) during the first few days after delivery should be provided to all newborns and their mothers as a concerted strategy to improve survival of both.”Maybe that’s why a woman’s female relatives gather round her while she’s pregnant and during delivery. Perhaps there’s something in the female psyche that knows this is a time of awful risk and danger, for both mother and child.

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WHILE there is not yet “a standardized, evidence-based PNC protocol,” there is some consensus on some of the more effective (and commonsensical, it seems) elements of care. The WHO has long recommended that postnatal care for all newborns should include “immediate and exclusive breast-feeding, warming of infants, hygienic care of the umbilical cord, and timely identification of danger signs with referral and treatment.”For mothers, recommended care includes monitoring and referral for complications such as excessive bleeding, pain and infection; counseling on breast care and breast-feeding; and advice on nutrition during breast-feeding, newborn care practices and family planning. Among the most crucial elements of any PNC program is a corps of skilled health providers, including midwives and health workers, who can visit newly delivered mothers and babies at home for initial care and advice-giving. Home visits are a necessity especially in developing countries, like the Philippines, because most deliveries are made at home, and social restrictions and traditions may even prevent a mother from leaving her home (or her room) to seek treatment.As the authors put it: “In most developing countries … postnatal care may only occur if provided through home visits, because geographic, financial and cultural barriers typically limit care outside the home during the early postnatal period.” “The essential elements of postnatal care for newborns and for women are already known and established,” say the authors. The issues remaining largely concern the integration of PNC protocols into the existing health system and, dare I say, the political will of leaders to give priority (and a commensurate share of the budget) to saving the lives of mothers and newborns when it counts most.